Will Health Reform Law Improve Health and Reduce Costs?

May 7, 2011 - I had a Canadian visitor today. He knew I was a doctor, and a commentator on U.S. health reform. He opened the conversation by saying, ”We love our health system. My brother was terribly ill with lymphoma, the treatment was long and expensive, and nobody even mentioned money.”

As he spoke, I thought. It must be wonderful to have such faith and admiration of a health system – with the government providing everything, and the dealings with it being so simple without financial worry.If only our health system were that simple, and we had such faith.

Back to planet U.S.A. I have little faith our one year old health reform law will either improve our national health, reduce costs, or lighten our national debt. Yet these are the stated goals of The Patient Protection and Affordable Care Act.

In a closely reasoned book, The Health of Nations; The Causes of Sickness and Well-Being(1987), Dr. Leonard Sagan, a Stanford epidemiologist, observed health care systems have little to do with reducing death rates or extending average live expectancy. Sagan said social, family, and personal factors loomed larger than health coverage. Medical care accounts for about 15% of the health status of any given population, life style for 20% to 30%, and other factors - poverty, inferior education, income differences, and lack of social cohesion - for the other 55% (Satcher, D, and Pamies,R. Multicultural Medicine and Health Differences, McGraw Hill, 2006). In my opinion, the Canadian culture, with its politeness and lack of violence, has more to do with its health than its health system.

Over the next 17 months, between now and the November 2012 Presidential election, Congress will debate whether to repeal, retain, defund, or change the law.

Let us examine the five main themes of the law as set forth in the Health Policy Newsletter, a publication of the Jefferson School of Population Health (T. Simmons, “Health Reform: Will it Improve Our Nation’s Health?” Spring 2011, Volume 24, Number 2).

• Expanding health care insurance coverage, including rebuilding the primary care workforce and resources for community health centers.

Comment: The law proposes to cover 32 million more citizens in 2014, 16 million of whom will be in Medicaid. What it fails to anticipate is that the Medicaid numbers may be much greater, as the recession drags on; as employers drop coverage because they cannot afford plans that meet federal standards; as less than 10% of medical students choose primary care careers; and as Congress cuts $600 million for federal funding for the nation’s community health centers, which now serve 23 million low-income patients.

• Adding new consumer protections and options, including a ban on denial for pre-existing conditions and banning insurance lifetime dollar limits.

Comment: These are worthwhile protections, but they come at the cost of increased premiums, which will rise at 10 to 12% in 2010-2011. These rising rates do not make coverage “more affordable.” They make coverage less “accessible,” and will force even more patients onto Medicaid rolls, the number one cause of state budget shortfalls.

• Making health care more affordable, including an emphasis on preventive care and the elimination of cost-sharing (co-pays and deductibles), closing the “donut hole” for the Medicare Part D prescription drug plan, and creating insurance exchanges that include tax credits for small businesses.

Comment: Seniors are not flocking to doctors for “free” colonoscopies and mammograms, or for 23 other “free” preventive services, partly because of unawareness of availability and partly because of the unpleasant nature of the services. Co-pays and deductible are increasing rather than decreasing. High deductible plans linked to health savings accounting now number more than 10 million. The donut hole closure is a good thing, but many states are resisting creating insurance exchanges, and small business is not impressed by tax credits, and their organizations, The National Chamber of Commerce and the National Association of Manufacturers, are actively lobbying to repeal Obamacare.

• Providing quality improvement measures including demonstration projects, enhancing continuity and integration of care through medical homes and accountable care organizations (ACOs) and expanding value-based purchasing.

Comment: Many in the physician and hospital communities regard these “measures” as high-toned rhetoric signifying federal power-plays that increase expenses of doing business, change the free enterprise culture, and require more rules, regulations, and harassment. “Quality” is in the mind of the beholder, and government definitions of “quality” do not match physicians’ definitions.

• Investing in prevention and expanding health programs, policies and incentives, giving all Americans the opportunity to lead healthier lives.

Comment: “Investing” and “expanding” federal programs on an increasingly broad is out of touch with the times, which call for austerity and cutbacks